Patient Forms 

Our fax is: 315-592-3571

medical record releases and pertinent information can be emailed to: amandah@riverviewpediatricsfulton.com

PATIENT OFFICE INFORMATION (Click to Download)

If your child is seen by a specialist or other health care facilities and needs a release to have records sent to our office, use the form below to do so. This ensures that we are able to receive medical records pertaining to your next appointment.

MEDICAL INFORMATION RELEASE FORM (Click to Download)

To transfer your care or your child(ren)’s care to another practice, please download the form below and drop off, mail, fax or email this form to: AMANDAH@RIVERVIEWPEDIATRICSFULTON.COM

TRANSFER OUT FORM (Click to Download)

To transfer care from another provider’s office to River View Pediatrics, please download the form below and drop off, mail, fax or email this form to: AMANDAH@RIVERVIEWPEDIATRICSFULTON.COM

TRANSFER IN FORM (Click to Download)

DAYCARE MEDICATION FORM (Click to Download)

                         River View Pediatrics HIPAA NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. TO REVIEW THE FULL DISCLOSURE PLEASE CONTACT THE OFFICE TO HAVE THE FORM EMAILED/MAILED OR TO PICK UP A COPY AT THE OFFICE.

If you have any questions about this notice please contact our Privacy Officer who is
Dr. Christopher DeLaney, 315-598-6785.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information, "Protected health information" is information about, including health information, that may identify you and that relates to your past, present, or future physical or mental health conditions and related healthcare services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised copy to be sent to you in the mail by calling our office or asking for one at the time of you next appointment.

           USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health care information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice.